HomeMy Public PortalAbout9725 WEDGEWOOD ST - Miscellaneous - 1989-06-23 WORKERS'COMPENSATION DECLARATION 76CE 8754(11-a4) MISCELLANEOUS APPLICATION
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN BUDDRDIESS 57:2S
LING
Z- wED6f6�-V&P SI—
Certified
Certified copy is hereby furnished. ADDRESS 97Z.4 �. �Gt112 69t.JOQ/7 $j LOCALITYTgyIP G1 •
FICertified copy is filed with the county building inspection LOCALITI— �-G NEAREST A�� W�S i
department. ��PL& G/• f- e:4, CRosS ST. `jj�[.
Date Applicant NEAREST /� // // �+ DISTRICT NO. G���QQQU ITYPE ,-irPROCESSED BY
CROSS ST. VvLP9_/Wf_S! r q CONST.
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGALU
COMPENSATION INSURANCE DESCRIPTION LOT NO. .3 BLOCK MAP HIGHWAY
NO. (CIRCLE) STATE MAJOR SECOND LOCAL
O. OF BLDGS.
N
(This section need not be completed if the work involved TRACT rp yl� NOW ON LOT , USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of e
SIZE OF LOT Z,�n I t0 EXISTING BLDG. Mks • / L�
I certify that in the performance of the work for which this I 6 0
permit is issued,I shall not employ any person in any manner OWNER �p ,('- J. )4W Sti y
so as to become subject to the r er' Co nsation Laws. MAIL �" �,�y� 5-1-1
� OCCUPANCY GROUP
MAIL. 0
ADDRESS 'Z� E, WAD615a4V'*R 71 J V
DateL'�-3-ti 1 Applicant
NOTICE TO APPLICANT: If, after making this Certificate of CITY�PL£ G/ TNrO.' OCCUPANT LOAD y
Exemption, you should become subject to the Workers' z
Compensation provisions of the Labor Code,you must forth- APPLICATION FOR EXIT HARDWARE:
with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION❑ No Spec. Knowl,
deemed revoked.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 11Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and /
effect. Z -4J T JF W/7-14 PARKING REq'D PROVIDED
SPACES I�
License Number Lic. Class D� Gil t- ;V G
LIMITED TIME USE
Contractor Date DATE OA TQ
❑ I am exempt from the licensing requirements as I am a FROM! T07
licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR'S
SPECTURE
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. aoo sroRlEs SI
iness and Professions Code). FINAL APPROVAL
v
Lie.or Reg.No. Date PRESENT USE OF BUILDING
l
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS s � G£
ON L07 AND USE 1 ........
I hereby affirm that I am exempt from the Contractor's AM.#
License Law for the following reason (Section 7031.5, Busi- 37 u�lo �l
F
d Professions Code): NO. PARKING as owner of the property, will do the work and the SPACES PROVIDED 1 ITSis
sructure is not intended or offered for sale (Section -
7044,Business and Professions Code). TOTAL 80.50
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING CAL'ILI 80.50
I hereby affirm that there is a construction lending agency ! .QCT
for the performance of the work for which this permit is
issued(Sec.3097,Civ.Q.
Lender's Name
da
PROPOSED MAX. OCG. # MM—Ml 4/23,V7
Lender's Address
I certify that I have read this application and state that the PERMIT FEE �� ' 41 1 80-07
above information is correct.I agree to comply with all County ISSUANCE FEE S
ordinances and State laws relating to building construction,
and her authorize represe tatives of this County to enter TOTAL FEE —
upon ie b e-me io d. r perty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date